Economy Getting You Down?

We here at Real Health Policy have been overwhelmed not only by the great conversations you have started, but also by the voracious demand for pug photos. We can only attribute this to the need of you, our readers, for more laughter and mini-doses of joy at this time of economic uncertainty. So to make the topic more uplifting, we are pleased to illustrate the first of three blogs on health reform with...well, you guessed it.

This entry was spurred by an e-mail from activist Fred Lennox of San Diego, CA. Truth be told, we enjoy serving as a sounding board for community health issues. We have even stooped so low as to post puppy videos. But our wonk-free guarantee prevents us from responding directly to the question: "If the public option is too expensive for a government with a massive budget, how can we expect people living hand to mouth to pay for private insurance, as required by Obama's health reform plan?"

Policymakers may not agree upon how to make America healthier, but what they have come to a consensus on is that the health care "system" is broken. The Obama Plan is a means of addressing the symptoms of this ailing system, most notably skyrocketing health care costs. But as Fred suggests, we don't have to tread far into wonky waters to recognize that as policymakers weigh the economic feasibility of a public health insurance option, many of us are worried about our ability to afford coverage if it is eventually mandated.

Putting 'Delivery' Back into Health Reform

Given that the mission of Real Health Policy is to put communities at the heart of public health dialogue, I want to dedicate the next two blogs to the issue of improving health care delivery. And I would love to hear from readers about whether you also feel this important issue has been overshadowed by current debates over health insurance reform.

This week a friend of mine drew a comparison between health care and cars, suggesting that like car insurance, health coverage should be mandated. My response was that if the auto industry were anything like health care, we'd be looking at $5,000 tune-ups and $350 gas bills (what I paid out-of-pocket for my last PCP visit, which lasted 5 minutes). The bottom line is that health insurance does not just cover us in the event of an accident. It has become synonymous with health care access, since even basic preventive care is so expensive.

Surely change agents should go beyond their current focus on coverage to ask whether health care is being delivered in an optimal way. Today we see physicians ordering unnecessary tests and referring us to specialist after specialist — and our medical bills growing — because this is the surest path toward maximizing profits (and avoiding a lawsuit). Yet it is easy for one to imagine a delivery system that is instead centered around the goal of maximizing health outcomes. We here at Real Health Policy submit that creating a health care delivery system that is more efficient, equitable and responsive to community needs is absolutely essential to driving down costs — and making health care accessible to all.

I begin here by outlining some of the basic issues to be addressed in improving health care accessibility. Next week I will provide a brief history of market competition in medicine to show how today's system is neither a perfect monopoly nor perfectly competitive — something that says a lot about the context in which Democrat and Republican proposals are operating.

The ABZs of Health Care Access

If you are like me and have had the joy of enrolling in a high-deductible insurance plan, then read no further. You understand what there is to know about issues with health care access. These issues are in my opinion driven by three primary factors: a) rising costs; b) insufficient insurance coverage; and z) a failing delivery system characterized by provider shortages, barriers relating to geography, race and ethnicity, socioeconomic status, and a focus on "sick care" as opposed to health.

Issue A: Rising Costs

Health care cost inflation is contributing both to the growing number of uninsured and to the rising prices that consumers face. Since 2000, the annual increase in insurance costs has been four times that of the accompanying growth in wages. As insurance becomes increasingly expensive, employers are cutting health coverage from their benefits packages and leaving workers to seek plans in the private market.

Unlike health plans purchased through employers, coverage purchased by individuals in the private market is not tax deductible. The result is that a growing number of Americans are choosing to remain uninsured or are purchasing catastrophic plans, which are cheaper than those that afford comprehensive coverage.

In either case, high out-of-pocket costs deter Americans from utilizing health care until they are very sick — and the benefit of a doctor’s visit is considered to be worth the high co-payment. For the uninsured, emergency rooms have become a primary point of access to the health care system, since the Emergency Medical Treatment and Active Labor Act requires emergency room staff to provide care to patients regardless of ability to pay.

Issue B: The Uninsured and Underinsured

More than 15 percent of Americans are currently uninsured. Millions more are underinsured, meaning they carry high-deductible plans that do not provide access to primary care for disease prevention or management of chronic conditions such as diabetes and asthma. In a country where preventive care and chronic disease management are not universally provided as a public good, coverage matters: People without continuous health coverage suffer poor health outcomes when compared to those who are insured.

Issue Z: An Inadequate Health Care Delivery System

While delivery models vary by state, with some like Massachusetts placing a greater emphasis on primary care, the majority of Americans have a delivery system that focuses on disease rather than wellness. People with high-deductible policies are choosing to forego preventive care, and those without insurance are relying upon emergency care, creating long wait times for everyone utilizing these services.

While there is conflicting evidence as to whether greater focus on preventive care will result in a net reduction of health care spending, there is general consensus that treating most illnesses before they reach an advanced stage is more cost-effective than providing labor- and technology-intensive urgent care. The current system is therefore inefficient in that it neither minimizes cost nor maximizes health outcomes.

One result of this inefficiency is that more and more physicians are seeking lucrative and prestigious careers in the medical specialties. Resulting shortages of primary care physicians and nurses has made access to primary care even more difficult, particularly in rural areas and impoverished communities where few providers choose to practice. Inadequacy of the public health delivery system is even more obvious when one considers that even when controlling for insurance status, geography and income level, racial and ethnic minorities are less likely than Caucasians to be able to access medical services.

Enough Already!

All right, all right...that is about as wonky as it is going to get. In keeping with our focus on health care delivery, I hope to feature a few examples (sent in by readers) of public and private organizations that have devised innovative and effective ways of delivering health care. Do you know of any good examples? Please send a suggestion or two to me via the contact page so that I can begin compiling your ideas!